OP Care Management RN

Carle Health•Champaign, IL

13h•Onsite

About The Position

The OP Care Management RN provides care management and population health services to patients, primarily targeting stratified risk patients or those with high vulnerability during care transitions. This role involves coordinating care for chronic diseases, facilitating medication management, and effectively managing care transitions across the continuum. The RN will develop personalized, longitudinal care plans for each patient, fostering partnerships among patients, families, nurses, physicians, and other healthcare disciplines. A data-driven approach will be used to manage patient populations, aiming to improve access to care and achieve optimal clinical outcomes. Carle Health is committed to a workplace where team members feel valued, respected, and empowered, impacting patients and communities. The organization has nearly 17,000 team members and providers, including eight hospitals and a multispecialty provider group across central and southeastern Illinois. Carle Health also develops future healthcare professionals through Carle Illinois College of Medicine and Methodist College, with several hospitals holding Magnet® designations for nursing care. They offer opportunities for growth and long-term careers.

Requirements

Certifications: Certified Case Manager within 2 years - Commission for Case Manager Certification (CCMC)
Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Education: College Diploma: Nursing (Required)
Work Experience: Nursing

Responsibilities

Communication and coordination between care settings across the healthcare continuum.
Identifies appropriate providers, healthcare organizations, and community services throughout the continuum of care and communicates with an interdisciplinary team to develop and maintain positive working relationships with patients, families and all other members of the care team.
Provide education on medication adherence, follow up appointments, and other activities to maximize patient knowledge of self-care and reduce avoidable readmissions.
Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
Conduct holistic health care assessment including health risk assessment, patient preference and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity and social determinants of health.
Ensure accurate documentation of clinical, financial, and other information using appropriate systems.
Utilize data, dashboard, or other reporting mechanisms to support high reliability performance and outcome evaluation.
Outpatient Care Management RN functions as an arm of the primary care provider to support any and all care coordination, chronic disease education for patients in collaboration with all cross-continuum care team members and support services.
Documents within patient Electronic Medical Record (EMR) to support departmental specific workflows to ensure accuracy in care planning efforts.
Effectively communicate with patients and all cross-continuum care team members in efforts to achieve optimal patient outcomes.